The Task List: What Unlicensed Staff May Do
A two-doctor practice employs three unlicensed optometric technicians and has a written "task list" prepared by the senior doctor. Technicians perform non-contact tonometry, auto-refraction, lensometry, and visual acuity; instill tropicamide 1% and phenylephrine 2.5%; perform Goldmann applanation tonometry; teach a patient to insert and remove soft lenses after the doctor has determined the parameters; run "vision therapy" sessions alone with a nine-year-old in a room out of sight; and telephone a patient to say "your pressure was 24, that's fine, no need to come back." Technicians also stamp the doctors' signatures on spectacle prescriptions. One technician selected a trial lens for a new wearer on her own and told her to wear it 12 hours a day. Both doctors are usually on site but in other rooms, and the vision therapy room is down the hall.
1. Sort the listed tasks into what may be delegated, what is doubtful, and what may not be delegated, and state the test you used.
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The governing test in Idaho is not difficulty - it is judgment. Delegable tasks are technical acts that do not require the knowledge, skill, and professional judgment of a licensed optometrist, performed under the level of supervision the rule specifies. That yields three buckets.
Clearly delegable, with the doctor reviewing the data: history, visual acuity, lensometry, non-contact tonometry, auto-refraction, visual-field screening, and insertion/removal training after the doctor has determined the lens parameters and wearing schedule.
Doubtful, and rule-dependent: instillation of diagnostic mydriatic/cycloplegic agents (commonly permitted under defined supervision, but confirm the current rule - including whether the doctor must be on site and whether the drops must be strictly diagnostic) and Goldmann applanation, which contacts the cornea and in many jurisdictions requires specific training and the doctor's immediate availability.
Not delegable: independent vision therapy sessions out of the doctor's sight; selecting a trial lens and setting a 12-hour wearing schedule (that is the professional judgment of fitting); telling a patient a pressure of 24 is "fine" - interpreting a finding and advising against return is the practice of optometry; and stamping a doctor's signature, which is a record-integrity and potentially forgery problem regardless of any delegation rule.
2. What is the supervising doctors' exposure, and what structure should the practice put in place?
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The doctors remain responsible for acts they delegate. Discipline exposure runs along three lines: aiding or abetting unlicensed practice, inadequate supervision of auxiliary personnel, and unprofessional conduct - plus, for the signature stamp, a falsification theory that is far more serious than a supervision lapse. Civil exposure sits with the practice as well, since the duty to the patient is the doctors'; a tech's reassurance does not insulate anyone.
The fix is concrete and documentable: a written delegation policy that lists permitted tasks and the supervision level for each; documented training and competency checks before a tech performs applanation or instills drops; a rule that any out-of-range or abnormal finding is communicated by the doctor, never by unlicensed staff, with a scripted phone response ("the doctor will review your results and call you"); doctors reviewing and initialing data before the chart closes; and individual credentials rather than a shared signature stamp, with each clinician signing electronically or by hand. The vision therapy program should be prescribed by the doctor, with the doctor observing progress and available on site. Run an internal audit of the last several months of charts to see whether the written policy matches what actually happened.
3. The patient who was told his pressure was "fine" skipped follow-up and returned 14 months later with advanced cupping. Analyze the practice's exposure and what should happen now.
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This is the worst version of the delegation problem because the practice did not merely fail to supervise - it affirmatively told the patient not to return. The plaintiff's theory writes itself: an unlicensed employee interpreted a clinical finding, gave reassurance outside any protocol, and the practice's own phone record proves it. Damages are the 14 months of uncontrolled pressure and the field loss that accrued.
On the regulatory side, expect a complaint alleging unlicensed practice and inadequate supervision, with the doctors answering for the tech's call. On the civil side, the practice is the defendant; the tech's conduct is the practice's conduct. The chart should not be altered now. What should exist going forward: a written telephone policy, a log of clinical calls with who said what, mandatory doctor review of every abnormal result before it is communicated, and a recall system that tracks patients who do not return. If a settlement or claim is anticipated, notify the malpractice carrier promptly and let counsel manage the internal review. The corrective actions matter to the Board, but they do not undo the 14 months.